Promising Models and Practices with Southeast Asian American

Communities

Zha Blong XiongUniversity of Minnesota

Yorn YanUnited Cambodian Association of

Minnesota

Overview of Presentation

• Context of Southeast Asian (SEA) Americans in Minnesota.

• The Citizen Health Care Model to build collaboration between the University and Southeast Asian communities.

• The Statewide Tobacco Education and Education Project (STEEP) Model.– Some evaluation data testing the model.

• Lessons learned.

SEA Resettlement in the United States, 1975-1994

5,000

10,000

15,000

20,000

25,000

30,000

35,000

40,000

1975-1976

1977-1978

1979-1980

1981-1982

1983-1984

1985-1986

1987-1988

1989-1990

1991-1992

1993-1994

U.S. Southeast Asian Population231,616 247,595 191,200

1,548,449

3,347,229

1,423,7842,555,923

2,843,391

1,938,393

Cambodian

Hmong

Lao

Vietnamese

Chinese

Korean

Filipino

Asian Indians

Others

Hmong (1.73%)

Lao (1.33%)Cambodian (1.73%)

Chinese

Vietnamese (10.82%)

Others

Korean

Asian Indians

Filipino

Minnesota Southeast Asian Population

Hmong; 26.1%

Asian Indian; 15.0%

Chinese; 11.4% Viet-

namese; 10.7%

Korean; 8.3%

Filipino; 6.2%

Laotian; 4.7%

Cambo-dian; 3.8%

Other; 13.3%

MN Asian population, by ethnicity

83%

5%

5%4%

1% 2%

Whites

Blacks

Hispanics

Asians

Native Americans

Multiracial

MN Population

4%

Hmong

Vietnamese

Most Southeast Asians in Minnesota concentrated in urban and poor areas

October 1, 2004 student enrollment

Address where one or more students live

Asian American Students in Saint Paul Public Schools

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• 53% of Minnesota’s Hmong population lives in Ramsey County and 45% within the City of St. Paul.• The Hmong comprise 57% of all Asians in Ramsey County nd 65% of Asians in St. Paul (2005-2009 American Community Survey 5-Year Estimates).

Percentage of Household Income below the Poverty Line in St. Paul, Ramsey and Hennepin Counties, MN by Race

CaucasianAfrican American Hispanic

American Indian

Asian-non Hmong

Hmong

St. Paul 3.4 19.2 12.8 17.8 25.8 33.9

Ramsey County

2.6 18.7 12.3 14.1 12.6 31.9

Hennepin County

1.7 19.5 12.7 20.2 6.3 33.7

Linguistically Isolated64%

59% 55% 52%44%

50%

33%42% 38% 35%

0%10%20%30%40%50%60%70%

Vietnamese Hmong Cambodian Laotian Chinese,except

Taiw anese

Limited English Proficiency Linguistically Isolated Households

Source: Census 2000 Data for Minnesota Population.

A recent study found that 81% of first generation respondents reported using a language other than English as their primary language, while 20% of second generation respondents also reported this (Robynn el al., 2010).

Smoking rates• Smoking rates in the general population are declining since 2004 (stalled at

20%)• Smoking rates in the SEA communities are still high.

– Some studies show that the prevalence rates for SEAs ages 18 and over ranged from 34% to 70% (Bautista, Ednacot, & Wong, 2005; Chen, 2001; McPhee et al., 1995).

– A 2009 study of 2,856 Hmong youth and adults in Wisconsin found that 15% of the youth ages 12-17 reported daily use and 32% ever use.

– The American Legacy Foundation (2001) reported that the number of Asian American teens who smoke increased from 4.4% in middle school to 33.1% by 12 th grade.

– Blue Cross and Blue Shield of Minnesota’s (2009) SEA study found that men are more likely to smoke (30%) than women (7%).

Engaging the Southeast Asian Communities to Address the Tobacco Use Problem

Community Engagement:

Buy-in & Planning

Capacity Building

Culturally Tailored,

Multi-Approached Education

Embedding and Systems

Change

Engaging the Southeast Asian Communities to Address the Tobacco Use Problem

Community Engagement Buy-in & Planning Model

Citizen Health Care Model’s Principles:1. The greatest untapped resource for strengthening families and

communities is the knowledge, wisdom, and lived experience of community members/citizens.

2. Citizens must be included in the engagement process as producers and contributors, and not a clients or consumers of services.

3. Researchers must come to the collaboration as citizen professionals to identify challenges, sources and nature of the problem, mobilize resources, and generate plans of action together.

Source: Doherty & Carroll, 2002; Doherty & Mendenhall, 2006.

Community Engagement Buy-in & Planning Process

Shared decision making and partnership building.

Capacity building for the collaborative & staff.

Identified stakeholders for the community leadership groups.

Community leadership groups.

Data collection: Stakeholder interviews.

Data collection: Focus groups.

Action plans & program development: Retreat.

The Engagement Process for the Statewide Tobacco Education and Engagement Project (STEEP) took 2 Years (supported by ClearWay Minnesota: 2005-2007):

The STEEP Project

• Mr. Yorn Yan

STEEP Logic Model

Inputs Outputs 3-YR Outcomes 5-YR Outcomes Impacts Activities

Blue Cross Blue Shield grant

Project manager Educators Office and meeting

space Access to community

members Marketing materials Commitment of

expertise, time, and energy of collaborative leadership

Volunteers Transportation

Plan, host, & participate in community events

Provide trainings Meet with community

leaders Work with groups on

policies & procedures Website & Blog Newsletter Advocacy Build network Continue outreach

activities Document, refine, &

report on the process of the project

Build capacity of Collaborative & individual agencies

STEEP has contacted and trained over 16,151 individuals.

Booth: 14,627

Workshop: 131

Quitline #: 689

Prof development: 587

Train-the-trainers: 117

Educators competencies increase and are able to train nationally

Conduct outcome evaluation Services are expanded to

other areas o Greater MN o Expand beyond SEA

communities STEEP visibility is increased A resource center has been

established Groups of volunteer trainers

are established statewide Communities and leaders are

educated and engaged in policy development and enforcement

Educate next generations of SEA in healthcare (embed in Jr. and Hgh school curriculum)

Community norms have changed—smoking is not associated with community events

People are supported in their efforts to stop smoking

No young SEA’s begin smoking

Smoking is considered an undesirable habit by community members

Target Populations: Southeast Asian and other Asian Communities in Minnesota

Situation: Tobacco use is a significant part of cultural events and an accepted habit connected to social interaction in the community

Needs: Some people don’t understand the impact of tobacco use on their health, the harm that second-hand smoke can do, and/or the addictive nature of tobacco

Program Purpose: Influence changes in community norms and practices and individual behavior through educating the community on the impact of tobacco use and engaging the community in spreading the information to promote change

Policies developed and enforced for participating organizations

Policies developed and promoted for smoke-free events

MN state law violations reduced

Fewer community celebrations (weddings/ funerals) involve tobacco

Increased understanding in SEA Communities of health impact

Match with workplan

Dandelion Systems Change

Capacity Building

Model: LAAMPP • Leadership and Advocacy Institute to Advance

Minnesota’s Priority Populations project (Lew, Honma,

Portugal, & Baezconde-Garbanati, 2008).– Build community and cross-cultural capacity for tobacco control– Developing a pool of Coaches

Approach: Train-the-trainers (Corelli et al., 2007; Orfaly et. el., 2005).

– Capacity building of the collaboration– Staff/Tobacco Educators– Volunteers: Community fellows– Allies: Community leaders– Community members

Community Engagement:

Buy-in & Planning

Capacity Building

Culturally Tailored, Multi-

Approached Education

Embedding and Systems

Change

Culturally Tailored, Multi-Approached Education• Setting: Places of congregation (“if we build it, people will come” is not

working )– Community events– Temples– Multi-housing units– Community-based organizations

• Materials: Posters, objects, tools, etc. (see samples)• Pedagogies: Story telling, demonstrations,

and role playing.• Evaluation: Pre- and post-tests; retrospective

Community Engagement:

Buy-in & Planning

Capacity Building

Culturally Tailored,

Multi-Approached Education

Embedding and

Systems Change

Chemical Poster

What it is: A poster depicting the chemicals present in cigarettes.

Why it is used: It is used to alert observers to the dangerous chemicals found in cigarettes.

Its message: The chemicals pictured in this poster are chemicals that many observers will recognize. This poster encourages smokers to ask themselves, “If these chemicals are used in each cigarette, why am I still smoking?

Retailer: Nimco Inc., www.nimcoinc.com, 1-800-962-6662, Fax: 1-270-273-5844

Tar Jar

What it is: This jar shows the amount of tar a smoker consumes in one year from smoking a pack (20 cigarettes) a day.Why it is used: It provides a visual picture of the tar that turns the lungs black.Its message: This educational tool teaches the effects of tobacco use on health.Retailer: Nimco Inc., www.nimcoinc.com, 1-800-962-6662, Fax: 1-270-273-5844

Community Engagement: Getting Communities & Institutions to Commit to Change

• Embedding practices and policies– Healthy living messages and practices

become part of each agency’s programs.– Co-presentations and team-focused

programs.

• Systems change practices and policies – Develop appropriate language for policies– Adopt policies– Implement and enforce adopted policies– Educate and inform existing state and local

policies

Community Engagement:

Buy-in & Planning

Capacity Building

Culturally Tailored,

Multi-Approached Education

Embedding and

Systems Change

Commit to Embedding and Systems Change

Action taken: 

Date Initiated Date Completed

Comments

Initial contact w/ member who knows someone in the entity.  

     

Talk with representative(s) of the entity about potential policy.  

     

Conversation with and/or present to group about potential policy.  

     

Have a conversation with the decision maker or the executive group.  

     

Present idea and language of policy and what the entity wants to cover. 

     

Help draft policy idea and language to the entity. 

     

Revise policy statement. 

     

Policy adopted.       

Community Engagement:

Buy-in & Planning

Capacity Building

Culturally Tailored,

Multi-Approached Education

Embedding and

Systems Change

NUMBER OF POLICIES PASSED

TYPE OF POLICY SYSTEMS

TOBACCO COMMUNITY BASED ORG.

TEMPLE GROUP MULTI- UNIT HOUSING

OTHERS

Hmong Soccer Tournament (1)

Tobacco X

No Tobacco Funding (5) Tobacco X

Strengthening Comprehensive Policy (5)

Tobacco X

World Refugee Day (1) Tobacco X

Multi-unit Housing (1) Tobacco X

Cambodian Temple (1) Tobacco X

Lao Temple (1) Tobacco X20% healthy options (5) Healthy Eating X

20% healthy options (1) Healthy Eating X

20% healthy options (1) Healthy Eating XBike racks (5) Active Living X

Lessons Learned

• Collaboration– Shared vision about the community well-being.– Trust and respect one another as professional citizens.– Commitment from the top of the organizations (i.e., executive directors).– Shared leadership and sacrifice at the collaborative level (chair committees, rally,

petition, cost to pay grant writer, etc.). – The role of the University in the collaboration is key to our program success (i.e.,

model development, grant writing, and evaluation).– The ongoing contributions of the TAs, consultants, and funders to guide, support,

and strengthen the collaboration.

• Staff– Capacity building is critical (i.e., demonstrate credibility, buy-in, and trust in the

community, esp. with young, second-generation staff). – Mentoring and coaching staff play an important role in our successes.– Organizational flexibility (in office vs. in the field).

Lessons Learned

• Evaluation– Evaluation is a challenge when working with low

literacy population.• The need to balance between delivering the

program vs. collecting data– An hour training with pre- and post-tests

– The challenge of using survey to collect data (i.e., response options; right and wrong answers).

– Reliable vs. practical measures.

Lessons Learned

• Volunteers– Challenge of retaining volunteers.– Challenge of getting volunteers to commit to advanced training

(tier three – two week training and a mentored project).

• Program– Build relationship with people is key to engagement, education,

and systems change.– If we move too quickly into systems change, the buy-in is not

there in the community to pass policies.– People need to personalize the problem before they can commit

to change.

Please don’t hesitate to contact us if you want to…• Learn more about the Citizen Health Care

Model to engage other immigrant and/or low SES communities;

• Learn more about our STEEP’s Dandelion and Systems Change Model;

• Have access to our evaluation data; or• Know more about our lessons learned and

other success stories.

CDC’s Program Evaluation FrameworkFramework for Program Evaluation in Public Health. MMWR 1999;48(No. RR-11)http://www.cdc.gov/eval/framework.htm

American Evaluation Association

Evaluation Standards• Utility: credible, negotiated, timely• Feasibility: practical, context, efficient• Propriety: formal agreements, conflict of

interest, transparency, inclusive• Accuracy: valid, reliable, justified• Accountability: documentation; internal &

external metaevaluationYarbrough, D. B., Shulha, L. M., Hopson, R. K., and Caruthers, F. A. The program evaluation standards: A guide for evaluators and evaluation users (3rd ed.). Thousand Oaks, CA: Sage; 2011 http://www.eval.org/evaluationdocuments/progeval.html

Evaluation

Address four evaluative questions: (1) How much have we been reaching out to the SEA

communities?

(2) How much do the people in the community know about STEEP?

(3) How much have we made a difference in the SEA communities?

(4) How much have we made a difference to the people we educated?

How much have we been penetrating the SEA communities?

• Conducted 65 events, delivered educational tools to 40,000 people in three target SEA locations: Twin Cities, Rochester, & St. Cloud.

• Recruited and trained over 120 volunteers; 20 of them delivered the education in their respective community.

• Networked/partnered with over 72 agencies and/or groups working on a variety of projects/activities in Minnesota.

How much do the people in the community know about STEEP?

• Nearly 97% of all survey respondents reported having seen STEEP at community events in the past year.• More than 50% of the survey respondents indicated hearing people talking “quite often” about STEEP’s work in their communities within the past year (2009-2010).

How much have we made a difference in the SEA communities?

How much have we made a difference to the people we educated? (Knowledge)

How much have we made a difference to the people we educated? (Smoking norms inside the home)

• Graph 11. Rules about not smoking inside the home

. Changing smoking norms inside the home

How much have we made a difference to the people we educated? (see smoking now vs. a year ago in the community)

13.2

38.9

11.1

22.6

8.9 12.1 15.3

34.2

79.5

50

81.1

60.5

82.173.2 71.6

48.9

5.3 5.8 4.2 8.4 6.8 8.9 10 11.1

0

1020

30

4050

60

7080

90

(n=186) (n=180) (n=183) (n=174) (n=186) (n=179) (n=184) (n=179)

Nowadays A yr ago Nowadays A yr ago Nowadays A yr ago Nowadays A yr ago

Inside restaurants Indoor worksites Inside publicbuilding

Inside funeralhomes

yes

no

not sure

How much have we made a difference to the people we educated? (see smoking now vs. a year ago in the community)

8085.3

60 62.6

47.9 51.6 51.1 52.6

7.92.1

12.68.9

36.3 33.237.4

31.6

7.9 5.3

23.7 22.1

11.1 8.4 9.5 11.1

0

10

20

30

40

50

60

70

80

90

(n=182) (n=176) (n=183) (n=178) (n=181) (n=177) (n=186) (n=181)

Nowadays A yr ago Nowadays A yr ago Nowadays A yr ago Nowadays A yr ago

Inside cars Outside thetemples

At communityevents

At the flea markets

yes

no

not sure

References

Bautista, R., Ednacot, E., & Wong, A. (2005, September). Asian Americans and Tobacco 101. An invitational workshop presented to the Minnesota Asian and Pacific Islanders

Community, St. Paul, Minnesota.Blue Cross and Blue Shield of Minnesota, ClearWay Minnesota, Asian Pacific Tobacco Coalition of Minnesota, & Southeast Asian Refugee Community Home (2009). Tobacco use in Minnesota: A quantitative survey of Cambodian, Hmong, Lao, and Vietnamese community members. Minneapolis, MN: ClearWay Minnesota.Bostrom, R. P., Anson, R., & Clawson, V. K. (1993). Group facilitation and group support systems. Group Support Systems: New Perspectives, 146-168.Brimmer, D. J., McCleary, K. K., Lupton, T. A., Faryna, K. M., Hynes, K., & Reeves, W. C. (2008). A train-the-trainer education and promotion program: Chronic fatigue

syndrome--a diagnostic and management challenge. BMC Medical DREGAN (2010). Burcum, J. (2008, May 7th). Breathe deeply and ponder this anniversary. Star tribune. Retrieved from: http://www.startribune.com/ opinion/commentary/ 18746919.html?

page=2&c=yCenters for Disease Control and Prevention (1999). Cigarette smoking among adults in the United States. MMWR, 48(43), 993-996.

References

Centers for Disease Control and Prevention (CDCP). (2004). New surgeon general’s report expands list of diseases caused by smoking. Retrieved at from January 8, 2006

from http://www.cdc.gov/tobacco/sgr/sgr_2004/pressrelease.htm.Centers for Disease Control and Prevention (CDCP). (2007). Reducing youth exposure to tobacco Influences, Best Practices: For Comprehensive Tobacco Control Programs. U.S. Department of Health and Human Services.Chen, M. S. (2001). The status of tobacco cessation research for Asian Americans and Pacific Islanders. Asian American and Pacific Islander Journal of Health, 9(1), 61-65.Council on Asian-Pacific Minnesotans and Minnesota Asian/American Health Coalition.

(2009). Health Disparities: An Asian American & Pacific Islander Community Response.Diverse Racial Ethnic Groups and Nations (DREGAN). (2006). Tobacco Use in Minnesota: Perspectives from Cambodian, Hmong, Laotian, and Vietnamese

Communities, Asian Pacific Tobacco-Free Coalition of Minnesota, Blue Cross and Blue Shield of Minnesota, Minnesota Partnership for Action Against Tobacco, Southeast Asian Refugee Community Home, March 2006.

Doherty, W. J., & Carroll, J. S. (2002). The families and democracy project. Family Process, 41, 579–589.

References

Doherty, W. J., & Mendenhall, T. J. (2006). Citizen health care: A model for engaging patients, families, and communities as co-producers of health. Families, Systems, & Health, 24(3),

251-263.Eastman, T. Are Tobacco Companies Targeting Asian Americans? Retrieved from:

http://www.helium.com/items/491813-are-tobacco-companies-targeting- Asian-AmericansGiovino, G. A. , Chaloupka, F. J., Hartman, A. M. et al. (2009). Cigarette Smoking Prevalence and Policies

in the 50 States: An Era of Change—The Robert Wood Johnson Foundation Impact Teen Tobacco Chart Book. Buffalo, NY: University at Buffalo, State University of New York.

Granner, M. L., & Sharpe, P. A. (2004). Evaluating community coalition characteristics and functionality: A summary of measurement tools. Health Education Research, 19(5), 514-532.Hoskins, L. & Angelica, E. (2005). Forming Alliances: Working together to achieve mutual goals.

Fieldstone Alliance.Jenkins, C. N. H., McPhee, S. J., Bonilla, N-T, Nam, T. V., & Chen A. (1995). Cigarette smoking among

Vietnamese immigrants in California. American Journal of Health Promotion, 9, 254-256.Jenkins, C. N. H., McPhee, S. J., Le, A., Pham, G. Q., Ha, N., & Stewart, S. (1997). The effectiveness of a media-led intervention to reduce smoking among Vietnamese-American men.

American Journal of Public Health, 87(6), 1031-1034.Lam, T. C. & Bengo, P. (2003). A comparison of three retrospective self-reporting methods of measuring change in instructional practice. American Journal of Evaluation, 24(1), 65-80.

References

Lew, R., Honma, J., Portugal, C., & Baezconde-Garbanati, L. (2008). The final evaluation report: Assessing the impact of Leadership and Advocacy Institute to Advance Minnesota’s Parity for Priority Populations [LAAMPP]. Minneapolis, MN: ClearWay Minnesota.Linn, R. L., & Slinde, J.A. (Winter 1977). The determination of the significance of change between pre- and post-testing periods. Review of Educational Research, XLVII, 121-50.Marcotty, J. (December 11, 2007). Statewide ban motivating Minnesota smokers to quit. Star Tribune. Retrieved from: http://www.startribune.com/lifestyle/ health/12340141.htmlMcPhee, S. J., Jenkins, C. N. H., Wong, C., et al. (1995). Smoking cessation intervention among Vietnamese Americans: A controlled trial. Tobacco Control, 4, 16-24.Minnesota State Demographer Center (n.d.). Immigrants in Minnesota. Retrieved from January 8, 2006 at http://www.demography.state.mn.us/Orfaly, R. A., Frances, J. C., Campbell, P., Whittemore, B., Joly, B., & Koh, H. (2005). Train-the-trainer as an educational model in public health preparedness. Journal of Public Health

Management and Practice, 11(6), S123-127. Pratt, C. C., McGuigan, W. M., & Katzev, A. R. (2000) Measuring program outcomes: Using retrospective pretest methodology. American Journal of Evaluation, 21(3), 341- 349.Eberle, Hogle, & Peterson (2011, June). Program evaluation and healthy equity research. Workshop

presented to the 2nd Annual Health Equity & Leadership Institute (HELI), University of Wisconsin-Madison.

References

Rumbaut, R. G. (1989). Portraits, patterns, and predictors of the refugee adaptation process: Results and reflections from the IHARP panel study. In D. W. Haines (Ed.), Refugees as immigrants: Cambodians, Laotians, and Vietnamese in America. Totowa, NJ: Rowman & Littlefield

Publishers, Inc.Sellnow, G. (2008, March 1st). Bar patrons light up under “Freedom to Breath Act,” Rochester (MN) Post-Bulletin. Retrieved from: http://www.postbulletin.com/ newsmanager/templates/localnews_story.asp Tobacco Law Center. (2009). Tracking tobacco laws: A Minnesota Digest, 2nd ed., Tobacco Law Center, St Paul, MN. U.S. Department of Health and Human Services.(2007). Best Practices: For Comprehensive Tobacco Control Programs. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention.Xiong, Z. B., Tuicomepee, A., LaBlanc, L., & Rainey, J. (2006). Hmong immigrants’ perceptions of family secrets and recipients of disclosure. Families in Society: The Journal of Contemporary Social Services, 87(2), 231-239.Yee, B. Health and health care of Southeast Asian American elders: Vietnamese, Cambodian, Hmong, and Laotian elders. University of Texas Medical Branch, Galveston. Retrieved

from: http://www.stanford.edu/group/ethnoger/southeastasian.html